S 0520 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL
PERMI'1'NO.BUILDING DIVISION APPLICATION/PERMIT PLUMBINIG-MECHANICAL 0520
BUILDING PROJECT IDENTIFICATION S v
r e SANITARY NO, APPLICATION SUBMITTAL DA
BUILDING AP_DRPSS:_9DAD
OWNER'SN A41440 w PHI,_ 7���,r CONTRA L 1 N NIC CONTROLN
ARCIII'I'ECT/ENGINEER�`:((�///WWgg"" LICCNN'Ori:_ '►VYWYI�fI ADDRES/:/a/ �1'��� ❑
CONTACT, OY�_J PHONE: BUILDING PERMIT INFO
'T/e_ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELryT PLUMB MF
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby st that 1 am licensed under provisions of Chapter 9(commencing
O�Z nulls,
of trotthe Husinasand f cions Cod.an mylicemkis RF ID NTIAL
tnOO PJ::f°5 PERMIT ISSUANCE. [ISFDW El KITCHEN REMODEL
Fly in full force vnd e0e /�J
�VF License Lic.N APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF.-PIPE.
EM7 Date�Cnmractor
Z F07� RCHITF:CTS tor
PANELS ❑MULTI-UNIT 1-1 STRUCTURAL
I undemmnd my plans shall bre usuA vv public,croons MODIFICATION
OZ- UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
r.Vdil❑il Licensed Professional IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEL/REPAIR [I DEMOLITION
Iqq I hereby a1Bnn that I um exempt from the Contmgor's License Law for the C3OTHE
X O c.U following reason.(Section 7031.5.Business and Professions Code:Any city or County SIGNS ELECTRICAL
W 3 a which requires a Permit to construct,alar,improve.demolish,or repair any nmcmre
O #norm its issuance.elw requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed......11.theindskinmofthe Contractors License Lw(Chapter 9 COMMERCIAL
'
M (commencing will Section 7000)ofllivisinn 3 ofthe Business and Professions Cods)or TEMP.METER OR POLE INST.
oh
aap(, a' m he is mcdopt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION [IDEMOLITION
1t1-,y Section 703 IS by any applicant for B permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
ZZ not more than five hundred dmi..($500). IMPROVEMENT
O E] I,us owner nY the property,or my employees with wages as their sole cn..i'mmia i, SWIMMING POOL ELECTRIC ❑OTHER
will do the work,and the structure is not intended,,,offered for sale(Sce.7(44,11 at.ss
PAI D
and Professions Code:The Conuncmr's License Law does not apply to all owner of OUTLETS-SWITCHES-FIXTURES
n' Property who builds or improves thereon,end who does such work himself if,through
his own employees,provided that such ireprovcmena are not intended.r offered for NEW RESIDENTIAL ELECTR SQ FT.
le.l[howevu,Ne builJing mrimpmvemem is wld within one year of cnmpletinn,the fN1R E 711 &SV.FL
owner builder will have the hooded of Passing that he did as,.build c r improve for par-as
{/
asofsaleJ. _ TOTAL: CITY OF GUrwiIINU
1,as owner of the progeny,am exclusively contracting with licensed contractors m
.nnotes the project(Sec.7014,Business and Profession Code:)The Contractors Li-
nseLaw diva not apply to an owner of Property,who builds in improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts far such projects with a contractods)licensed pursuant o the Contractors
License Law. PERMIT ISSUANCE
1 um exempt under Sec. .B A P C for this reason
ALTER-DRAIN N VEND'-WATER(EA) � pA LI- JpsCo
Owner Date /�r�/((�ajJ�oJl//�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I hereby eNren under penalty of Pe Jury one of the following decluratinns:
�Have and will maintain a Cenificote of Convento self-insure for Worker's Comped. DRAINS-FLOOR.ROOF AREA.COND. STORIES TYPE C(INSTRUCI'ID
Cation,as Provided for by Section 3700of the",C,Cada,for the performance of the
for which Nla pmanu is ismed. FIXTURES-PER TRAP
so,I have and will maintain Workers Compensation Insurance,as required by Section
3700ofthe Labor Cale.for the
onnan of the work for which this Permit is issued. GAS-EA.SYSTEM-1 INC 40UTLET3 OCC.GROUP APN
My Workee u nJ lain c c -, d PolicPolicy nutaher�Ci/M / GAS-EA.SYSTEMOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'✓f GRP.ASf%INDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he completed ifthe permit is formas,hundred dollnrs($100) GREASETRAP
PLANCHF.CK Plili
or less.(
Loy say N. in performance nfthe Work
econn Whichthisto thepermitW.imm issued. SEWER-SANITARY-STORM EA.2(N)fT. ENERGY I'Eli
not employ any person in any manner set as m hecome subject m the Workere'Compcn-
z cation laws of Califrmia.Date WATER BEATER WNENIVELECR GRADING FEE
z O Applicant l
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING
F 'N' SOILS HEbecome subject to the Werkds Compensation provisions of the Lahr Code,you must
�i forthwith comply with such provisions.,,his Permit shall be deemed revoked. WATERSERVICE
{JJ Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.pT. PAID
bks Date Revella#
(.1 p l hereby effireathanhem is a construction lending agency for the Performance of
{Iw the work for which this permit is coned(Sec,3097,Civ.C.) TOTAL:
O U Iandcrs Name TOTAI;
WI.cndcr's Address BUILDING FEE
g4 1 cenify that 1 have read this application and ante that the love amommtion is
Lncorrect.l agree to coen
comply with all city and county ordi...resdamtaluwFE
sreliedgm QTY, MECHANICAL PERMIT FEE SEISMICE
VG building contraction.and hodyumhonce representatives ofthis city m enter upon the
aln ve-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC PRE
(We)agree m save,indemnify and keep honnlesa the City of Cupertino against
liabilities,judgments,.,is andexpenws whiehmay in any wayiw,rmiBainsr said City AUTER OR ADD TO MUCH. PLUMBING FEE
in consequence of the granting of this pemnit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT AIR HANDI.I NO UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
' AIR HANDLING UNITfOVER 10,0(1()CPM) CONSTRUCTION TAX '
Signature of ApplicardC.ntmel0a Dnte EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle burardnu.0 mmenaL III"ATING U N I'I'(TO I(N),0N1 BTU)
as defncd by the Cupertino Municipal Code,Chapter 9.12,and the Hculth unit Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(8)1
❑Yes 1z° VENTILATION FAN(SINGLE RESID) PAID Dao Receipt#
will the applicant fomre building oceupar use equipment or devices which BOILER-COMP(3HPOR IM.000RTU)
emit hvuNoas is run INC
defined by the Bay Area Air Quality Management TOTAL:
Dimict? BOILER-COMP(OVER 100,000BTU)
❑Yes AIR CONDITIONER ISSUANCE DATE
1 have rextenuls requirements under Chapter M195 of the Culi- /I
fomite Health afmy de,Secrions 25505,25533.M 25534.I understand than if the NEW RESIDEN'T'IAL MECH. SQ.Fr.
h 1 Co hu sou orad fa ar ois my resm.Celhy to nn'fy the nccupam
n yt s h so be met Pnor to issuanceofe Cenifi"c fpr y.
O or au the sed]aBem CS Dam TOTAL: ISSUED BY:
OFFICE 5p. OD